The Arts in Psychotherapy 33 (2006) 3758

The treatment of aggression using arts therapies in forensic psychiatry: Results of a qualitative inquiry
Henk Smeijsters Ph.D. a, , Gorry Cleven RDT b
a KenVaK, Centre of Expertise for the Arts Therapies, Zuyd University, the University of Professional Education Utrecht, and Saxion University of Professional Education Enschede, PO Box 69, 6130 AB Sittard, The Netherlands b GGzE, the Institute for Forensic and Intensive Psychiatry, Eindhoven, The Netherlands

Abstract The article describes the body of knowledge of arts therapies in forensic psychiatry based on recent practice, theory and research. The rst part gives an overview of observational details, interventions, effects and rationales of drama therapy, music therapy, art therapy and dance-movement therapy in general and more specically in the Netherlands. It shows that arts therapies can help to decrease recidivism. In the second part the results are presented of a qualitative naturalistic inquiry with 31 experienced arts therapists working in 12 institutions in the Netherlands and Germany. The arts therapists have been involved by means of semi-structured questionnaires, interviews and focus groups. Their implicit knowledge about indications, goals, interventions, effects and rationales have been compared and integrated into consensus-based treatment methods. The research reects the Dutch tradition where all arts therapies are developed and researched within the same methodological formats. The results of one of the problem areas that have been researched, destructive aggression, are presented. Finally a comparison has been made between all arts therapies for the treatment of destructive aggression. 2005 Elsevier Inc. All rights reserved.
Keywords: Arts therapies; Forensic psychiatry; Qualitative research; Aggression

Corresponding author. Tel.: +31 46 4207262; fax: +31 46 4207279. E-mail address: h.smeijsters@hszuyd.nl (H. Smeijsters). URL: www.smeijsters.nl, www.kenvak.hszuyd.nl. 0197-4556/$ see front matter 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2005.07.001

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Introduction In the Netherlands health care system, arts therapies are a regular part of treatment in psychiatric and forensic psychiatry. Nowadays there is strong pressure to become evidencebased. For this reason there is a need for arts therapists, and other therapists as well, to develop treatment protocols and treatment guidelines based on research. To start with, arts therapists describe their observations, goals, interventions, effects and rationales when working with specic problems. What prompted this research, which lasted several years, was the lack of a research-based overview of these aspects of treatment for all arts therapies in forensic psychiatry. Because arts therapists had started describing their work individually, the authors decided by means of questionnaires, interviews and focus groups to accumulate and analyze this material further. All arts therapies (drama therapy, music therapy, art therapy, dance-movement therapy) were included. The research reects the Dutch tradition where all arts therapies are united in one national association and arts therapies are developed and researched within the same methodical formats and compared to each other. The rst part of this article describes the context for forensic psychiatric treatment and the status of arts therapies in forensic psychiatry. A summary of the published research is included, which gives an overview of the state of the arts in forensic psychiatry. The second part of the article describes the research method and results. Forensic psychiatric treatment in the Netherlands Forensic psychiatry is an important concern in the Netherlands. Many forensic patients are treated in special forensic mental health institutes and will be released to the community sooner or later. For offenders who, at the time of the crime, had a psychiatric disturbance, for instance psychosis, personality disorder or addiction, it is agreed that they need treatment rst before they can be released. These offenders are treated as clients in psychiatric hospitals that are closed from the community. Patients are imprisoned, but within the institution there is a psychiatric, not a prison culture. Although these patients are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), in several psychiatric hospitals the focus of treatment is on so-called problem areas. Problem areas are related to the DSM-IV and the chain of offense. Broek (2000a, 2000b) distinguishes the following problem areas: lack of impulse control, aggression, grief, lack of empathy, low social functioning and lack of structure. H orschl ager (2000a, 2000b), in her follow-up of the research by Damen (2000, 2001), mentions problem areas such as tension, aggression, impulsivity, power, control, lack of boundaries, lack of structure, lack of expression and inadequate perception. Factor analytic research with the Behavioural Status Index (Woods, Reed, & Collins, 2001) shows that there are factors for social perception, assertiveness and non-verbal behavior as problem areas for this population. Arts therapies in forensic psychiatry in the Netherlands In the Netherlands arts therapies are a regular part of multidisciplinary treatment in most psychiatric institutions. The number of arts therapists working in forensic institutions is

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about 10% of the working population of arts therapists. However, there is no difference in the relative frequency of art therapists working in forensic and general psychiatry. In general and forensic psychiatry arts therapists from different modalities (drama, music, art, dance-movement) work together in teams and take part in the overall treatment plan. Based on their observations, they collect supportive information for the process of diagnosis, which is determined by the psychiatrist. Treatment in a forensic institution is made up as an integrated program in which several professionalspsychiatrist, psychologist, arts therapists, and otherstake part. Within the treatment program, arts therapists focus on specic treatment goals. In the Netherlands the arts therapies in the last decade developed from insight oriented therapy that takes the personality as a focus, to changing the way the patient feels, thinks and acts in concrete, here-and-now situations. The arts therapies became more re-educative, which means that the patient is trained to change specic cognitions, feelings and behaviors related to one problem area. This makes arts therapies valuable ingredients in the treatment of forensic patients. An important rationale for arts therapies in forensic psychiatry is their orientation to action (Douma, 1994; Hakvoort & Emmerik, 2001). The experiential and active nature of the arts therapies makes concrete goals like regulation of tension, impulse control, regulation of aggression, the planning and structuring of behavior and the development of interaction competencies possible. A general theory of arts therapies, for psychiatry as well as forensic psychiatry, has been articulated by Smeijsters (2003a, 2003b, 2003c, 2005). In line with Sterns developmental psychology (Stern, 1985, 1995), Smeijsters describes the analogy between the vitality affects of the psyche and the dynamic processes during the expression in the art form, which both are characterized by equal basic parameters like dynamics, tempo, rhythm and form. The therapeutic process is possible because the change of expression in the art form is experienced as a change of vitality affects. By experiencing vitality affects in art forms forensic patients can work through unarticulated layers of experiences and gradually become conscious of cognitive schemes (Johnson, 2002; Kampen, 2004; Timmer, 2004). Drama therapy in forensic psychiatry Forensic patients in dramatherapy are unable to improvise, to take roles and to distinguish between their own point of view and some elses point of view (Thompson, 1999). Thompson (1998, 1999) developed workshops like Joe Blaggs and The Pump. The Joe Blaggs workshop involves a ctitious offender about whom the patients ask questions like: Who is Joe Blaggs?, What is he doing?, What are his thoughts?, Who is inuenced by him?. By means of these questions the patients develop a story with characters and events. The story is played, and by means of stop-rules, it is possible to reect and explore alternative behavior. The Pump is a workshop in which patients learn to distinguish between Knocks (facts that cannot be changed), Wind-ups (provocations, threats by others) and Pumps (inner thoughts and interpretations that increase anger). Patients are trained how to decrease pumping thoughts and to manage their anger. Timmer (2000a, 2000b, 2000c, 2003, 2004) uses the chain of offense developed by Mulder (1995) in drama therapy. Together with the patient she develops a play in which crucial moments of the chain of offense are incorporated. The patient reects on these

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Table 1 Recidivism 2 years after patients have been dismissed from supportive treatment Length of treatment No more than 6 months 712 months 1318 months 1924 months More than 2 years Source: Teasdale (1997). Recidivism (%) 67 56 45 21 17

moments with words like who, where, and when. We see that typical aspects of drama therapy are perfect ingredients to be incorporated in a cognitivebehavioral treatment. What makes drama therapy a strong primary treatment is the fact that the behavior is trained in concrete play situations. Landers (2002) starts from the perspective that people who have been victims in society choose the role of offender because this role is easily available. By means of playing the roles of offender and victim, by changing scenes, and commenting on scenes patients acquire a more varied role pattern. Cleven (1998a, 1998b, 1999, 2003, 2004) developed interventions in which patients play different stages of life, including the stages that lead to the offense. Teasdale (1997) describes psychodrama and art therapy as part of a supportive treatment modality within a forensic therapeutic community in which the whole community and also smaller groups have group therapy sessions. This community as a whole leads to a remarkable decrease of recidivism (see Table 1). This shows that the success of treatment increases with the length of treatment. Although it is not possible to infer from this data the specic contribution of art therapy and psychodrama, the characteristics of these therapies are closely connected to the rationale of the therapeutic community: decreasing individual impulsivity and crime. In drama therapy playing situations form daily life and using role changes to enhance the ability to see things from the perspective of another person led to a decrease in offenses of 50% during the follow-up measurement of a treatment group compared to a placebo and control group (Chandler, 1973). Therapeutic theater for persons who committed armed robbery and abuse led to the decrease of anxiety, the increase of empathy and the ability to handle conicts (Cogan & Paulson, 1998). Thompson (1999) takes the similarity between cognitivebehavioral therapy and the process of the actor who changes his cognitions to play his role. He tells us that everyday life is staged, and that it is a matter of rehearsing and playing the appropriate role in real life that saves patients from getting into an offense. A patient can leave the role of the bad guy and choose the role of the good guy. The combination of reecting and rehearsing the performance of the good guy is how drama therapy works. Because pathology in forensic psychiatry is complex, Cleven (2004) uses several rationales adopted from Gestalt psychology, transactional analysis, self-psychology and developmental psychology. Music therapy in forensic psychiatry Flower (1993) and Santos (1996) describe how forensic patients in music therapy are unable to improvise. These patients either control themselves to the extreme or are unable

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to stop their acting out behavior and act aggressively. Anger can be heard in the tempo, the dynamics, and the sound of the patients play (Hakvoort, 1996, 2002a, 2002b). There are many goals that are listed by music therapists working in forensic psychiatry such as relaxation, self expression, mood change, emotional development, self-esteem, respect for others, social interaction and adjustment, release of tension and anxiety, anger management, decrease of aggressive behavior, self-control and coping skills (Codding, 2002; Fulford, 2002; Gallagher & Steele, 2002; Rio & Tenney, 2002; Thaut, 1987, 1992; Watson, 2002). Thaut mentions that for these patients short-term therapy in the here-andnow with realistic goals is appropriate. The music therapist can use the monochord, background music, music listening, song selection, song parody, song composition, lyric analysis, group singing, drumming, and vocal and instrumental improvisation with themes your competencies, your beliefs, your identity (Daveson & Edwards, 2001; Gallagher & Steele, 2002; Hakvoort, 2002a; Reed, 2002; Watson, 2002; Wyatt, 2002; Poel, 1997). Flower (1993), in her work with delinquent adolescents, focuses on their helplessness and negative identity. To increase the patients control of his or her environment, Flower takes destructive family situations as a theme and together with the patient explores musical territory during which the patient can experiment with levels of control. The patient reaches a balance when he or she is able to take initiatives and lead the improvisation and also is able to give space to another person, which he or she supports and follows. Flower uses thematic improvisations like The giant and the dwarf and The spider and the y. Wagner (1997), Argante (1999), and Peeters (2003) developed interventions based on three themes: the development history, the offense and empathy for the victim. Music therapists report effects of music therapy on anxiety, tension, hostility, ghting behavior, frustration tolerance, impulse control, attention span, reality perception, awareness of others, and self-perception (Codding, 2002; Hoskyns, 1988; Thaut, 1989a, 1989b, 1992). A review of session documentation by Gallagher and Steele (2002) of 188 patients showed that 91% actively participated, 82% expressed thoughts and feelings and 68% had a positive change in affect. The drum improvisation between patient and music therapist leads to a control of anger (Drieschner, 1997). Watson (2002) reports the following effects of drumming: selfexpression and awareness of emotions, appropriate social interaction and cooperation, and coping skills. Research of Daveson and Edwards (2001), a self-report study after 12 sessions, shows that ve female delinquents in a prison reported being more relaxed and experiencing less tension and stress and were able to express themselves better after music therapy. All patients reported that music therapy was pleasant and helpful. Song composition and song parody led to more self-expression. Listening to songs and singing songs led to more relaxation. Singing, song composition, song parody and listening to songs decreased stress, anger and frustration. The effect of music in forensic psychiatry can be explained by referring to its possibilities for interaction, communication, expression and exploration of feelings, as well as its ability to stimulate goal-oriented behavior and create possibilities for controlling emotions and behaviors (Codding, 2002; Gallagher & Steele, 2002). Theoretical concepts that are used may be related to psychodynamic theories, behavioral approaches, and cognitive procedures

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(Rio & Tenney, 2002). An explanation for the effect of drumming with patients who have themselves been traumatized is given by Skaggs (1997), who argues that trauma is imprinted in the body, and that drumming by inuencing the body can evoke emotions. Drieschner describes that the effect of the drum improvisation can be explained by referring to the theory of analogy (Drieschner, 1997, and in Smeijsters, 2003c, 2005). Other music therapists also stress the analogy between offensive and manipulative impulses and behaviors, and the behavior during the musical improvisation (Hakvoort, 2002a; Hakvoort & Emmerik, 2001; Poel, 1997, 1998). By changing the parameters of the musical expression, the behavioral, emotional and cognitive parameters of the offense can be changed. Art therapy in forensic psychiatry In art therapy assessment instruments are used, such as the House-Tree-Person Test (Buck, 1987), the Expressive Therapy Continuum and the Media Dimension Variables (Lusebrink, 1990), and the Draw a Story Test (Silver & Ellison, 1995). Research by LevWiesel and Hershkovitz (2000) with the Machover Draw-A-Person Test shows a statistically signicant difference in signs of violent behavior between violent and non-violent offenders. Lopez and Carolan (2001) with the House-Tree-Person Test found a similar difference. Goals which are used in art therapy in forensic psychiatry are self-expression, selfesteem, coping mechanisms, social competencies, breakthrough of defenses, openness for the offense, insight in thoughts, feelings and actions that triggered the offense, selfcontrol, alternative behaviors and empathy for the victim (Bennink, Gussak, & Skoran, 2003; Gerber, 1994; Kampen, 2001). The patient can work through childhood experiences; compare thoughts and feelings while being a victim and offender, and express feelings to others. The patient can reect on the form, the content, the emotional expression and the cognitive distortions in the artwork. Bennink et al. use collages that are constructed with journals, objects trouv es and oil pastels to balance the planning, controlling and expression by means of cognitive and behavioral instructions. The art therapist (and co-therapist) acts as a model, and together with the patient rules are described that shape behavior. The use of simple steps of progress helps to minimize the patients frustration and to maximize success experiences. Giving patients the opportunity to make choices prevents opposition. Art therapy in forensic psychiatry often takes place within the framework of cognitivebehavioral psychotherapy in which the problem is explored and then the search for a solution is undertaken (Kampen, 2001). Artistic expression of emotions instead of acting out aggressive behavior can serve as a coping mechanism. Haeyen (2004) shows that it is possible for patients to express emotional polarities in art, and gain insight into inner contradictions from the perspective of dialecticalbehavioral therapy in line with Linehan (1996). It is possible to integrate these contradictions in a work of art and decrease aggressive and destructive impulses. By doing this, patients can prevent their levels of increasing emotional tension from getting out of control and ultimately culminating in an offense. There are few research results of art therapy in forensic psychiatry (Bennink et al., 2003). Several authors report that art therapy increases the insights patients have into

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their personal thoughts, beliefs and behaviors as well as the thoughts, beliefs and behaviors of others (Gussak, 1997; Gussak & Cohen-Liebmann, 2001; Gussak & Virshup, 1997; Liebmann, 1996a, 1996b, 1998). The case vignettes described by Bennink et al. show that patients, by drawing a volcano, express their anger symbolically if they are unable to express it verbally and cognitively. After feelings have found an expression in the artwork patients are enabled to talk about it. The feedback of others increases selfesteem. Riches (1998) reports a 29% reduction of disciplinary measures in a prison as a result of 13 months of art therapy. The amount of transgressions requiring disciplinary measures as a result of art therapy decreased 7581%. Two years after patients were dismissed 69% of the persons who took part in art therapy did not re-offend compared to the control group without art therapy, which in 42% did not re-offend (Brewster, 1983; Peaker & Vincent, 1990). Art therapists in forensic psychiatry have used two prominent rationales. One is based on the premise that patients can communicate in art in a symbolic way that cannot be verbalized (Liebmann, 1998). This may be linked to Freuds or Jungs psychoanalytic concepts of the manifest and latent meaning of images and Winnicotts concept of symbolic play (Murphy, 1998; Winnicott, 1971). In these rationales the patients artwork refers to content behind the image. The goal of therapy is nding these latent meanings to reach insight in fragmented psychic content and conicts (Hagood, 1998). From a different perspective, the art process and art form as an expression of the patients thoughts, emotions and behaviors is used rather than the symbolic meaning of the patients images (Baeten, 2001, 2005; McCourt, 1998; Riches, 1998). Important in this perspective is how the patient uses the brush and color, arranges the space on the paper, works with details and the whole, makes transfers, and so on. These actions show how the patient experiences and acts. The goal of therapy is then to help the patient nd new ways of experiencing and acting. Dance-movement therapy in forensic psychiatry In Europe dance-movement therapy is not very well represented in forensic psychiatry. Although this section does little justice to the possibilities dance-movement therapy might have in forensic psychiatry it is included to show its potency. In dance-movement therapy Laban Movement Analysis (Laban, 1998) forms the basis for a variety of different assessment measures that can be used to analyze the body and movement parameters of forensic patients. Presenting yourself through movement increases individuation. Moving synchronously in the same rhythm increases social behavior and bonding (Milliken, 2002). Dance-movement therapy makes it possible to work with tension increases and decreases. Slow movements, conscious relaxation and eye contact counteract impulsive, brusque, uncontrolled and antisocial behavior. In her study DiGiorgio (1988) describes several theoretical perspectives when working with aggression. Currently, there are no published studies of the effect of dance-movement therapy with the forensic psychiatric population. However, there are meta-analyses that show that dancemovement therapy is effective with psychiatric populations (Cruz & Salbers, 1998).

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Dalessi (1997) describes how in dance-movement therapy movement games can be used that show almost no difference from the offensive act. The patient can use his body to hunt the therapist or another patient into a corner of the room. The same physical, emotional and behavioral processes are evoked as have been experienced in the offensive act. But there is analogy because in therapy this is play and not a real offensive act. The dance-movement therapist by means of rules can offer the opportunity on the one hand to experience the same physical, emotional and behavioral processes, and on the other hand to put these into play where they can be controlled and where there is no harm done to others. Suddenly increasing tension in movement followed by releasing this tension is an example how in dance-movement therapy tension increase and tension release can be explored and controlled (Milliken, 2002).

Research question and research method The research reported here focused on nding which problem areas are important in actual clinical practice, how they can be dened, and which observations, indications, goals, interventions, effects and rationales arts therapists use when working with one particular problem area with the population of interest. We also addressed the issue of consensus about the treatment of any particular problem area within and between the arts therapies. The aim was to develop treatment methods with a sufcient amount of clinical trustworthiness. The research methodology was based on qualitative data, naturalistic (on site) inquiry, and dialectical knowledge-building. This implies an authentic dialogue between practitioners and researcher, in which treatment methods are developed, by reconstructing tacit knowledge of experienced arts therapists (Polanyi, 1967). The outcome represents subjective meanings that have been negotiated. Specic research techniques used were repeated analysis of transcripts, iterative member checking with respondents, peer debrieng with independent experts, triangulation (multiple respondents with different training and experience, multiple data collection techniques such as open questionnaires, interviews and panels, multiple theoretical perspectives), concept development and categorizing from grounded theory, and content analysis as described in the work of Lincoln and Guba (1985, 2000), Smeijsters (1997), Strauss and Corbin (1998), Charmaz (2000), and Schwandt (2000). Problem areas were conceptualized as diagnostic categories. Within these problem areas the researcher asked questions such as: How would you describe this problem area? Do you have a diagnostic theory about the problem area? How is the problem behavior reected in drama, music, art, dance or movement? Which aspects of the problem area do you focus on during therapy? What are your goals? Which method, play forms and techniques do you use? Which effects did you see? Do you have a rationale why drama, music, art, dance or movement has a positive effect? These questions reect the following framework: problem area, observation, diagnosis, indication, goal, intervention, effect, and rationale, which can be understood as a way of axial coding (Strauss & Corbin, 1998). Within the framework concepts were developed by means of the constant comparative method: comparing data from the same individuals with themselves,

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comparing data from different people, comparing incident with incident, comparing data with category, and comparing a category with other categories (Charmaz, 2000; Glaser, 1992). Respondents were 31 members of the network of arts therapists in forensic psychiatry. They were working in 12 forensic clinics in the Netherlands and Germany. As data collecting techniques questionnaires, interviews, and expert panels were used. Several arts therapists participated in more than one data collecting technique. Nineteen arts therapists received by e-mail an open questionnaire with a set of problem areas and the listed framework above and were asked to write down their tacit knowledge. All written descriptions were analyzed by comparing, selecting, relocating, combining, and integrating content (Mayring, 1990). Smeijsters acted as the researcher, Cleven as coreader. The researcher analyzed each individual questionnaire and also made cross-analyses of all questionnaires for a specic problem area and modality. There were several cycles in which the results of analysis went back and forth between (new) respondents and the researcher. Because of gaps in the data, ve arts therapists were interviewed to ll these gaps using theoretical sampling (Charmaz, 2000). The researcher used the same framework while discussing the tacit knowledge of the therapist when working with specic problem areas. During these interviews, by taking his own understanding into the dialogue, the researcher in a dialogical encounter tested the arts therapists understandings, and thus critical involvement produced understanding on both sides. During the interviews the researcher wrote down the therapists answers into the framework. The transcripts of the interviews were compared with the results of the questionnaires. Finally 15 arts therapists participated in expert panels in which they discussed with colleagues the trustworthiness of the researchers cross-analysis of the questionnaires and interviews. Some people participated in several stages of the research process, but in total 31 different persons were involved (11 drama therapists, 9 music therapists, 8 art therapists and 3 dance-movement therapists). During all stages in the research process member checking, peer debrieng, the triangulation of theoretical perspectives, and the use of several data collection techniques increased credibility and dependability. Peer debrieng with the members of the KenVaK research team was used to secure conrmability.

Results The project began using the preliminary denitions of 11 problem areas by H orschl ager (2000a) were used (see also H orschl ager & Cleven, 2002). The outcome resulted in seven consensus-based problem areas and treatment models. Within the scope of this article it is only possible to describe one problem area. A complete description of the research results (in Dutch) can be found in Smeijsters and Cleven (2004). Table 2 gives an overview of treatment possibilities for the problem area of destructive aggression. This table is the result of the researchers content analysis of all open questionnaires, interviews and panel discussions as described above.

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Table 2 Consensus-based results of the treatment of destructive aggression by means of arts therapies (selection of data) Drama therapy Indications Regular aggressive behaviors Music therapy Lack of contact with own aggressive feelings Avoiding conicts Unable to regulate aggression To make contact with ones aggressive feelings To permit and express aggression Art therapy Being irritated quickly Dance-movement therapy Uncontrolled aggressive outbursts during which the patient cannot control his body Screaming and expressing anger in interaction Unable to control aggression Insight in the process of aggression development To handle power and lack of power, being big and small To handle frustration, tension, anger, anxiety, aggression, violence Being able to reconstruct risky events To accept that suppressing feelings leads to uncontrolled outbursts To learn how to express feelings without hurting oneself and other people Sublimation of destructive aggression into constructive aggression General line of treatment: H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758

Lack of insight in own aggression Unable to regulate aggression Goals Insight into ones personal aggression history Insight into stimuli that evoke aggression and the process of aggression development Recognition of ones personal aggression thermometer and ones non-verbal signals of aggression Being able to use techniques of aggression to decrease aggression Being able to handle stimuli that evoke aggression Being able to stop aggression immediately Sublimation of destructive aggression into constructive aggression Interventions General line of treatment:

Suppressed anger that explodes in uncontrolled destructive aggression Unable to regulate aggression Insight into the process of aggression development Recognizing risky events

Aggression regulation

To handle cognitions and feelings during events that might lead to an offense Developing self control during risky events To handle aggression

Being able to handle conicts

Sublimation of destructive aggression into constructive aggression

General line of treatment:

General line of treatment:

Reach insight into and change aggressive behavior Activities Going through the aggression history in several life times Scene work to explore:

Reach insight into and change aggressive behavior Activities Together with the music therapist play The cat that hunts, and kills the mouse, exchanging roles Express feelings like anger and aggression; one person is playing, the other is guessing which feeling has been expressed Choosing on a scale from 0 to 100 which level of aggression the patient wants to express. Rising the level aggression from 0 to the level that has been chosen and going back A ght on musical instruments

Reach insight into and change aggressive behavior Activities Working with water paint, using another color before the rst one is dry Alternating between constructing and deconstructing (destroying, burning, tearing apart) Exploding within borders

Reach insight into and change aggressive behavior Activities Learn how to experience the increase of aggression through body signals Learn how to decrease the increase of aggression by means of changing body reactions When aggression increases focusing on functional movements

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Sorts of aggression

Cognitions and emotions

Gradual exposure to materials with resistance (hardness, weight, format):

Role-play of events where the patient acted aggressively

YES/NO plays

Working with stones

Using an aggression thermometer (010) to schedule events linked to levels of aggression Role-play low risk events from daily practice and increasing the tension level, then: Confronting, looking for the most frustrating stimulus of the event

Improvisation on percussions

Working with strong physical efforts

Using strength in controlled situations and movements (tug of war) where you can hurt nobody Thematic techniques: power and lack of power, big and small, anger, aggression, violence, anxiety, hyperactivity, tension, frustration Playing: Hunter and hare

Using words including feelings, destructive coping behavior (aggression, drugs abuse) Giving structure to aggression by learning how to play the drums

Depicting how the patient looses control in the offense (sudden changes in the art process) Painting stop signals

Defending your territory

Catch and free

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Table 2 (Continued ) Drama therapy Learn how to stop the behavioral outburst Exploring alternative behaviors Connecting the low risk event with the offense Learn to anticipate high risk situations in the future The boxing ring Scene work with high status roles Pretended ghts Theatre of statues, tableaux vivants Joe Blaggs Effects Insight in ones personal aggression increases Acting differently in conict situations outside therapy For instance: Not hitting Less experience of stress, anger and frustration A decrease of anger Supporting others Music therapy Researching the cognitions, feelings and behaviors during the offense Playing the victim on the musical instrument Art therapy Painting lack of power Dance-movement therapy Pretended ghts (hitting at a distance) Fighting with sticks against the wall and with cushions Techniques of distancing Using rules during play and stops

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Painting ones mist between inner power and outer burdens Painting ones pitfalls Learn how to behave different

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Openness to the offense Feeling responsible for the offense Perceive risk factors Insight into ones cognitive distortions Reecting ones personal development and experiences Experiencing the victim as innocent

Admitting ones anger To understand and control ones anger Expressing power in a controlled way Express aggression at the right moment and in the right way Being more relaxed To understand ones borders and stop behavior at an early stage Behaving differently

Staying at a distance Using a time out (visiting ones room) Not slapping with doors Not screaming

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The consensus-based rationales that were developed as a result of the research are described below. Rationales Drama therapy Drama therapy allows distancing so it is possible to analyze cognitions before and during aggression. Because of ctive dramatic play the patient can explore aggressive scenes and reach insight into stimuli and his or her cognitions. The patient can reach insight into his or her inner conicts concerning status and respect. Dramatic play gives the opportunity to develop the ability to regulate aggression. This ability can be transferred to realistic role-play. Music therapy Musical instruments and parameters offer the opportunity to express aggression in a constructive way. The aggressive energy can become a part of the musical process. The music therapist can take part in the aggressive outburst, contain it and help the patient to express and regulate his aggression. Working in the music and being contained by the music therapist gives the patient a feeling of security when exploring his aggression. Art therapy In art therapy materials and techniques can be used to evoke and release aggression. Expressing aggression in art material safely helps to explore ones aggression. Using art materials makes it possible to be in contact with ones cognitions, feelings and behaviors. Visual art forms make it possible to picture the events, cognitions, feelings and behaviors that went along with the persons crime. By reecting on the image the patient can be confronted. Behaviors like grasping, hitting or petting can be transformed into artistic behaviors. Dance-movement therapy Aggressive behaviors have strong body and movement characteristics. Dance-movement therapy works with body and movement and therefore can evoke destructive bodily and movemental powers. Patients are afraid of their destructive behaviors, which are suppressed but suddenly can come to an outburst. They did not learn to symbolically express power less destructively. In dance-movement therapy, dance and movement are used to express suppressed destructive aggression in an acceptable way, and to nd alternative behaviors. Comments All arts therapists sampled chose a lack of aggression regulation as an indication for treatment. Drama, art, and dance-movement therapists mentioned aggressive behavior. Drama therapists also focused on a lack of insight, music therapists on a lack of contact with personal feelings and avoiding conicts, and art therapists on the saving up of anger. All arts therapists used reaching insight as a goal. Learning how to control aggression stimuli was used in drama, art, and dance-movement therapy. Drama, art, and dancemovement therapists also took the transfer of destructive into constructive aggression as

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a goal. Music and dance-movement therapists mentioned accepting and releasing aggression. Drama and art therapists focused on stopping aggression. Drama therapists also chose relaxation as a goal, music therapists handling conicts, art therapists controlling thoughts and feelings, and dance-movement therapists handling power and lack of power. There were many interventions. All modalities used playforms for power and status, pretended ghts and quarrel in the art form. Drama, music and art therapists explored thoughts, feelings, and behaviors during the offense. Drama, art, and dance-movement therapists used stop rules. Drama and music therapists worked with an aggression thermometer. Art and dance-movement therapists worked with control giving way to power. Drama therapists went into the aggression history, and also played little risk situations from daily life. Music therapists worked with frustration tolerance training and used play forms to express feelings. Drama and dance-movement therapy indicated as an effect the ability to react differently. Music and dance-movement therapy led to a decrease of anger. Music therapy resulted in a change of feeling, art therapy in the decrease of cognitive distortions, and dance-movement therapy in expressing anger in a more controlled way. Drama therapists saw as a rationale for the effect of drama therapy the possibility to explore by distancing and ctive role cognitions and to explore and train alternative behaviors. Music therapists saw the musical instruments, the musical parameters, and the musical interaction as an opportunity to express aggression in a social context and to learn how to control it. Art therapists mentioned the characteristics of the art material as a possibility to experiment with the expression of aggression. Depicting the offense in an image in their opinion was a means to decrease cognitive distortions. Dance-movement therapists stressed the fact that in dance and movement the physical aspect of destructive aggression are expressed and changed. Table 3 gives a summary of all therapeutic categories for all arts therapies. In Table 3, in most cases a coherent clinical reasoning process can be seen, which means that all aspects of treatment (indication, goal, intervention, effect, rationale) were connected to each other. Sometimes, however, the link between treatments aspects was not manifest. Table 4 based on Table 3, shows how the clinical reasoning process can become explicit for all treatment aspects. The authors additions have been put in italics.

Discussion From the literature it can be seen that arts therapies strongly focus on behavior and emotions. The play forms are aimed to go into life history, to express emotions, to interact, and to strengthen social, emotional, physical and cognitive competencies. Arts therapies work with a combination of experiencing and acting; with a stable structure in the art form. Patients learn how to think, feel and act differently as well as give different meanings to their experiences. This is possible because in arts therapies concrete scenes are explored in which it is almost impossible to hide ones thoughts, emotions, and behavior. Arts therapies explore the onset and characteristics of the offense and help patients to recognize and inuence the thoughts, feelings and behavioral signals that are linked to the offense. Through structured play formswith roles, scenes, listening exercises, improvisations, art images and forms, body exercises, and movement arrangementsbehaviors,

H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758 Table 3 Summary of the treatment of destructive aggression by means of arts therapies Drama Indications Lack of aggression regulation Aggressive behaviors Lack of insight Lack of contact with ones feelings To avoid conicts Suppressing anger Goals To reach insight To control aggression stimuli To transform destructive in constructive behavior To express aggression To stop aggression Relaxation To handle conicts To control cognitions and feelings To handle power and lack of power Interventions Playforms with power and status Pretended ghts Exploring cognitions, feelings and behaviors Stop rules Aggression thermometer Controlled strength Aggression history Low risk events Frustration tolerance training Expression of feelings Effects Behaving differently Less anger Change of feeling Less cognitive distortion Expressing anger differently Rationales Distancing in ctive scenes and roles Musical instruments, parameters and interaction Obstinate art material Imaging Expression in body and movement Music Art

51

Dancemovement X X

X X X

X X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

feelings and cognitions are transformed. Attachment problems, developmental and psychiatric disturbances are positively inuenced by strengthening self-expression, self-esteem and empathy. A shared rationale of arts therapists is that by expressing thoughts, feelings and actions in art forms it is possible to inuence these expressions hands on and explore and develop new thoughts, feelings and actions.

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Table 4 Examples of coherent clinical reasoning process Indication Drama Music Aggressive behaviors Lack of contact with ones feelings Lack of insight Lack of aggression regulation Goal To control aggression stimuli To contact personal feelings Intervention Low risk events Expression of feelings Effect Behaving differently Change of feeling Rationale Distancing in ctive scenes and roles Musical instruments, parameters and interaction Imaging Expression in body and movement

Art Dance-movement

To reach insight To transform destructive into constructive behavior

Exploring cognitions, feelings and behaviors Controlled strength

Less cognitive distortion Expressing anger differently

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The research resulted in several consensus-based areas of treatment such as patients limited perception, compulsive control, lack of emotional expression and empathy, high emotional tension, impulsivity, lack of interpersonal boundaries, and destructive aggression. These problem areas form a bridge between disturbances and offensive behaviors. Impulsivity for instance is related to addiction; limited perception is related to psychotic disturbances. Other problem areas are related to personality disorders, attention decit hyperactivity disorder, and mental handicaps. When the offense has been committed by a patient with a particular disturbance, the problem areas that are connected to this disturbance will be the focus of treatment. Interventions in drama, music, art, dance, and movement show the psychological limitations and possibilities of patients. The arts therapies confront forensic patients with their lack of emotions, dysfunction of cognitions and behaviors. By experiencing and acting it is possible to increase tension regulation, impulse control, aggression regulation, empathy, interaction, and the strengthening of boundaries. This research makes explicit the tacit knowledge of a group of arts therapists. By doing this it is possible to analyze, compare and integrate the implicit body of knowledge this group of arts therapists developed while working with their patients. This research made a cross-analysis of tacit knowledge of several arts therapists, which resulted in a consensus-based body of knowledge, the collective sense of the profession so to speak. The effects listed in this research study reect the effects as perceived by the surveyed arts therapists. These effects are consensus-based, but not experimentally researched. Therefore, we are planning another research study of effects that is closely linked to clinical practice, but is more experimentally oriented, in which baseline phases, treatment phases and control conditions are precisely observed and correlated with other assessment scales like scales for recidivism. The results of this qualitative study will act as an input for the next research study and we hope to transform these data into an assessment scale and treatment plan. The arts therapists reported experiencing this interaction with the researcher as very fruitful because they were stimulated to reect on their experiences and conceptualize what they were doing. For them, this led to empowerment that they hoped would strengthen their future treatment interventions and also their rationales within their multidisciplinary teams. Hopefully, due to this research where respondents at several stages were confronted with analyses of data, the reective practitioner could develop into a scientic practitioner who not only acts as an individual respondent, but also as a co-researcher. Because the respondents acted as co-researchers, this may have led to an increase of their scientic competencies. The information gathered by this research can be used in everyday clinical practice when the goal is to inuence destructive aggression of forensic patients. The body of knowledge is consensus-based, as listed in Table 2. However, this information should not be used as a protocol without variation. Each individual art therapist should reect on the transferability of these data to his or her own setting and patients.

Acknowledgements Thanks to all arts therapists and students who participated in this research. Thanks to the members of the KenVaK team who were involved with peer debrieng. This research is a

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joint project by KenVaK, and the GGzE, the Institute for Forensic and Intensive Psychiatry in Eindhoven. The research results have been published as a book by the EFP, the national Centre of Expertise for Forensic Psychiatry in Utrecht. Thanks to Cheyenne Mize at the University of Louisville for her advice in preparing this article. References
Argante, R. (1999). Muziektherapie ten behoeve van het dagprogramma seksueel delinquenten [Music therapy for a day treatment program of sexual delinquents]. Workshop gehouden tijdens de SCRET-studiedag Dagbehandeling van zedendelinquenten [Workshop during the SCRET Symposium Day treatment of sexual delinquents]. Eindhoven: GGzE. Baeten, N. (2001). Observatie en analyze van beeldend werk [Observation and analysis of art work]. Workshop tijdens de Studiedag Creatief Therapeuten binnen de Forensische Psychiatrie [Workshop during the Symposium Arts Therapies in Forensic Psychiatry]. Utrecht: Dr. F.S. Meijerskliniek. Baeten, N. (2005). Beeldende therapie creatieve therapie in de praktijk [Creative art therapy in practice]. Utrecht: Flevo Future. Bennink, J., Gussak, D. E., & Skowran, M. (2003). The role of the art therapist in a Juvenile Justice Setting. The Arts in Psychotherapy, 30(3), 163173. Brewster, L. G. (1983). An evaluation of the arts-in-corrections programme of the California Department of Corrections. Prepared for the William James Association, Santa Cruz, California and California Department of Corrections. Broek, R. van den (2000a). Inleiding over de Pompekliniek [Introduction about the Pompe clinic]. Studiedag Dramatherapeuten in de Forensische Psychiatrie [Symposium Dramatherapists in Forensic Psychiatry], Nijmegen. Broek, R. van den (2000b). Workshop empathie [Workshop empathy]. Studiedag Dramatherapeuten in de Forensische Psychiatrie [Symposium Dramatherapists in Forensic Psychiatry], Nijmegen. Buck, J. N. (1987). House tree person test. Los Angeles, CA: Western Psychological Services. Chandler, M. (1973). Egocentrism and antisocial behaviour: The assessment and training of social perspective taking skills. Developmental Psychology, 44, 326333. Charmaz, K. (2000). Grounded theory objectivist and constuctivist methods. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 509535). London: Sage Publications. Cleven, G. (1998a). De toepassing van vaktherapie en in de daderbehandeling [Arts therapies in the treatment of offenders]. Eindhoven: GGzE FPC. Cleven, G. (1998b). Van inspiratie naar integratie. Over observatiemethodiek in dramatherapie [From inspiration to integration. Assessment in drama therapy]. Tijdschrift voor Creatieve Therapie, 17(4), 2023. Cleven, G. (1999). Dramatherapie ten behoeve van het dagprogramma seksueel delinquenten [Drama therapy as part of the day treatment program for sexual delinquents]. Workshop gehouden tijdens de SCRET-studiedag Dagbehandeling van zedendelinquenten [Workshop during the SCRET Symposium Day treatment of sexual delinquents]. Eindhoven: GGzE. Cleven, G. (2003). Het rollenrepertoire van cli enten met een persoonlijkheidsstoornis. Het rollenrepertoire is driedimensionale actie [The role repertoire of clients with a personality disturbance. The role repertoire is three-dimensional action]. In I. Graumans (Red.). Storing verplicht?! Over het onvermogen emoties te hanteren (pp. 2128) [Disturbance obliged?! About the helplessness to handle emotions]. Eindhoven: GGzE. Cleven, G. (2004). In Sc` ene. Dramatherapie en ervaringsgerichte werkvormen in hulpverlening en begeleiding [In sc` ene. Drama therapy and experiential play forms in treatment and support]. Houten: Bohn Staeu van Loghum. Codding, P. A. (2002). A comprehensive survey of music therapists practicing in correctional psychiatry: Demographics, conditions of employment, service position, assessment, therapeutic objectives, and related values of the therapist. Music Therapy Perspectives, 20(2), 5668. Cogan, K. B., & Paulson, B. L. (1998). Picking up the pieces: Brief report on inmates experiences of a family violence drama project. The Arts in Psychotherapy, 25(1), 3743. Cruz, R. F., & Sabers, D. L. (1998). Dance/movement therapy is more effective than previously reported. The Arts in Psychotherapy, 25(2), 101104.

H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758

55

Dalessi, A. (1997). Roofdieren in een kooi. Danstherapie in de behandeling van een groep zedendelinquenten [Animals in a cage. Dance therapy in the treatment of a group of sexual delinquents]. Tijdschrift voor Creatieve Therapie, 16(3), 2631. Damen, M. (2000). Indicatiestelling bij de non-verbale therapie en van het forensisch psychiatrisch circuit van de GGzE. Een concept mapping project ter ontwikkeling van een indicatieschaal [Indications for nonverbal therapies in the forensic psychiatric unit of the GGzE. A concept mapping project for the development of an indication scale]. Eindverslag, Eindhoven: GGzE. Damen, M. (2001). Een indicatieschaal voor de non-verbale therapie en [An indication scale for nonverbal therapies]. Tijdschrift voor Creatieve Therapie, 20(1), 2023. Daveson, B. A., & Edwards, J. (2001). A descriptive study exploring the role of music therapy in prisons. The Arts in Psychotherapy, 28(2), 137141. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). (1994). American Psychiatric Association. DiGiorgio, D. (1988). Three theoretical perspectives on aggression with implications in the eld of dance/movement therapy. Philadelphia: Hahnemann University. Douma, N. (1994). Kreatieve therapie onder dwang? [Creative therapy under pressure]. Tijdschrift voor Kreatieve Therapie, 13(4), 126128. Drieschner, K. (1997). Vermindering van boosheid door muziektherapie: een gecontroleerd effectonderzoek met forensisch psychiatrische cli enten [The reduction of anger by means of music therapy: A controlled effect study with forensic psychiatric clients]. Amsterdam: Universiteit van Amsterdam. Flower, C. (1993). Control and creativity. Music therapy with adolescents in secure care. In M. Heal & T. Wigram (Eds.), Music therapy in health and education (pp. 4045). London: Jessica Kingsley Publishers. Fulford, M. (2002). Overview of a music therapy program at a maximum security unit of a state psychiatric facility. Music Therapy Perspectives, 20(2), 112116. Gallagher, L. M., & Steele, A. L. (2002). Music therapy with offenders in a substance abuse/mental illness treatment program. Music Therapy Perspectives, 20(2), 117122. Gerber, J. (1994). The use of art therapy in juvenile sex offender specic treatment. The Arts in Psychotherapy, 21(5), 367374. Glaser, B. G. (1992). Basics of grounded theory analysis: Emergence versus forcing. Mill Valley, CA: Sociology Press. Gussak, D. (1997). Breaking through barriers: Art therapy in prisons. In D. Gussak & E. Virshup (Eds.), Drawing time: Art therapy in prisons and other correctional settings. Chicago, IL: Magnolia Street. Gussak, D., & Cohen-Liebmann, M. (2001). Investigation versus intervention: Forensic art therapy and art therapy in forensics settings. American Journal of Art Therapy, 40(2), 123135. Gussak, D., & Virshup, E. (Eds.). (1997). Drawing time: Art therapy in prisons and other correctional settings. Chicago, IL: Magnolia Street. Haeyen, S. (2004). Verbindend werk. Beeldende therapie met borderline-cli enten op basis van de dialectische gedragstherapie van Linehan [Work that connects. Art therapy with borderline clients based on the dialectical behaviortherapy of Linehan]. Tijdschrift voor Creatieve Therapie, 23(1), 510. Hagood, M. (1998). Group art therapy with adolescent sex offenders. An American experience. In M. Liebmann (Ed.), Art therapy with offenders (pp. 197219). London: Jessica Kingsley Publishers. Hakvoort, L. (1996). Patterns between indication for music therapy and characteristics of musical improvisation of forensic patients. Paper presented at the 8th World Congress of Music Therapy, Hamburg. Hakvoort, L. (2002a). A music therapy anger management program for forensic offenders. Music Therapy Perspectives, 20(2), 123132. Hakvoort, L. (2002b). Observation and treatment criteria in music therapy for forensic patients. Paper presented at the 10th World Congress of Music Therapy, Oxford. Hakvoort, L. & Emmerik, J. van (2001). Diagnostiek en observatie in de Dr. F.S. Meijerskliniek [Diagnosis and observation in the Dr. F.S. Meijers clinic]. Presentatie tijdens de Studiedag Creatief Therapeuten binnen de Forensische Psychiatrie [Presentation during the Symposium Arts Therapies in Forensic Psychiatry]. Utrecht: Dr. F.S. Meijerskliniek. H orschl ager, K. (2000a). Indicatiestelling bij de non-verbale therapie en van het forensisch psychiatrisch circuit van de GGzE. Deel II Work in progress. Operationalisatie van probleemgebieden ter ontwikkeling van een indicatieschaal [Indications for nonverbal therapies in the forensic psychiatric unit of the GGzE Part II Work

56

H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758

in progress. Operationalization of problem areas for the development of an indication scale]. Eindverslag, Eindhoven: GGzE. H orschl ager, K. (2000b). Indicatiestelling bij de non-verbale therapie en van het forensisch psychiatrisch circuit van de GGzE. Deel III. Op weg van een individuele waarneming en beschrijving naar een gemeenschappelijke waarneming en beschrijving van probleemgebieden [Indications for nonverbal therapies in the forensic psychiatric unit of the GGzE. Part III. From individual perception and description to the collective perception and description of problem areas]. Eindverslag, Eindhoven: GGzE. H orschl ager, K., & Cleven, G. (2002). Indicatiestelling bij non-verbale therapie en van het forensisch psychiatrisch cirquit van de GGzE [Indications for nonverbal therapies in the forensic psychiatric unit of the GGzE]. Lezing tijdens het NVCT Symposium, 7 juni [Paper presented during the NVCT Symposium]. Hoskyns, S. (1988). Studying group music therapy with adult offenders: Research in progress. Psychology of Music, 16, 2541. Johnson, D. R. (2002). Creatieve therapie bij getraumatiseerde mensen [Creative therapy for traumatized people]. Lezing tijdens het Symposium Tijdsbesef van de NVCT [Paper presented during the Symposium Time consciousness of the NVCT]. Kampen, E. (2001). Module creatieve therapie beeldend. Zorgprogramma 3 Seksuele stoornissen: delictketen groep [Treatment module creative art therapy. Treatment program 3 sexual disturbances: Chain of offense group]. Venray: De Rooyse Wissel. Kampen, E. (2004). De innerlijke observator als bewaker van delinquent gedrag. De reectieve functie als aangrijpingspunt en maat voor behandeling [The inner perspector as guard of delinquent behavior. Reection as indication and measure for treatment]. Tijdschrift voor Creatieve Therapie, 23(2), 813. Laban, R. (1998). The mastery of movement. Plymouth: Northcote House Publishers. Landers, F. (2002). Dismantling violent forms of masculinity through developmental transformations. The Arts in Psychotherapy, 29(1), 1929. Lev-Wiesel, R., & Hershkovitz, D. (2000). Detecting violent aggressive behavior among male prisoners through the Machover Draw-A-Person Test. The Arts in Psychotherapy, 27(3), 171177. Liebmann, M. (1996a). Arts approaches to conict. London: Jessica Kingsley Publishers. Liebmann, M. (1996b). The violent illusion: Drama therapy and the dangerous voyage to the heart of change. In M. Liebmann (Ed.), Arts approaches to conict (pp. 92117). London: Jessica Kingsley Publishers. Liebmann, M. (Ed.). (1998). Art therapy with offenders. London: Jessica Kingsley Publishers. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications. Lincoln, Y. S., & Guba, E. G. (2000). Paradigmatic controversies, contradictions, and emerging conuences. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 163188). London: Sage Publications. Linehan, M. M. (1996). Borderline persoonlijkheidsstoornis. Handleiding voor training en therapie [Bordeline personality disorders. Manual for training and therapy]. Lisse: Swets & Zeitlinger. Lopez, J. R., & Carolan, R. (2001). House-tree-person drawings and sex offenders: A pilot study. Art Therapy, 18(3), 158165. Lusebrink, V. B. (1990). Imagery and visual expression in therapy. New York: Plenum Press. Mayring, P. (1990). Qualitative Inhaltsanalyse. Grundlagen und Techniken [Qualitative content analysis. Fundamentals and techniques]. Weinheim: Deutscher Studien Verlag. McCourt, E. (1998). Building up to a sunset. In M. Liebmann (Ed.), Art therapy with offenders (pp. 3956). London: Jessica Kingsley Publishers. Milliken, R. (2002). Dance/movement therapy as a creative arts therapy approach in prison to the treatment of violence. The Arts in Psychotherapy, 29(4), 203206. Mulder, J. (1995). Het terugvalpreventiemodel als behandelingsmethodiek in een forensische dagbehandelingskliniek [The prevention of recidive model als treatment method in a forensic day treatment clinic]. Tijdschrift voor Psychotherapie, 21(2), 119133. Murphy, J. (1998). Mists and darkness. Art therapy with long term prisoners in a high security prisonA therapeutic paradox? In M. Liebmann (Ed.), Art therapy with offenders (pp. 1438). London: Jessica Kingsley Publishers. Peaker, A., & Vincent, J. (1990, December). Arts in prisons: Towards a sense of achievement. Home Ofce Research and Planning Unit and the Arts Council. Peeters, R. (2003). Workshop persoonlijkheidstoornissen en zedendelinquenten. Emoties binnen de themas ontwikkelingsgeschiedenis, delictscenario en slachtofferempathie van een eendaagse deeltijd [Workshop per-

H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758

57

sonality disorders and sequal delinquents. Emotions within the themes developmental history, offense scenario and victim empathy of a one day parttime treatment]. In I. Graumans (Red.). Storing verplicht?! Over het onvermogen emoties te hanteren [Disturbance obliged?! About the helplessness to handle emotions]. Studiedag SCRET, Eindhoven: GGzE. Poel, T. van der (1997). Musiktherapie mit pers onlichkeitsgest orten sexualstraft atern in der Forensischen Psychiatrie [Music therapy in the treatment of sexual delinquents with personality disorders in forensic psychiatry]. In Hast du T one? Musik und Musiktherapie im Rheinland [Do you have sounds? Music and music therapy in the Rheinland]. K oln: Landschaftverband Rheinland. Poel, T. van der (1998). Musiktherapie mit pers onlichkeitsgest orten sexualstraft atern in der Forensischen Psychiatrie [Music therapy in the treatment of sexual delinquents with personality disorders in forensic psychiatry] (p. 5). WsFPP. Polanyi, M. (1967). The tacit dimension. London: Routledge Kegan Paul. Reed, K. J. (2002). Music therapy treatment groups for mentally disordered offenders in a state hospital setting. Music Therapy Perspectives, 20(2), 98104. Riches, C. (1998). The hidden therapy of a prison art education programme. In M. Liebmann (Ed.), Art therapy with offenders (pp. 77101). Jessica Kingsley Publishers: London. Rio, R. E., & Tenney, K. S. (2002). Music therapy for juvenile offenders in residential treatment. Music Therapy Perspectives, 20(2), 8997. Santos, K. (1996). Woman patients in forensic psychiatryThe forgotten ones? In I. Nygaard Pedersen & L. Ole Bonde (Eds.). Music therapy within multidisciplinary teams. Proceedings of the 3rd European Music Therapy Conference (pp. 121127). Aalborg: Aalborg Universitetsforlag. Schwandt, T. A. (2000). Three epistemological stances for qualitative inquiry. Interpretivism, hermeneutics, and social constructionism. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 189213). London: Sage Publications. Silver, R., & Ellison, J. (1995). Identifying and assessing self-images in drawings by delinquent adolescents. The Arts in Psychotherapy, 22(4), 339352. Skaggs, R. (1997). Music-centered creative arts in a sex offender treatment program for male juveniles. Music Therapy Perspectives, 15(2), 7378. Smeijsters, H. (1997). Multiple perspectives. A guide for qualitative research in music therapy. Gilsum, NH: Barcelona Publishers. Smeijsters, H. (2003a). Analogie als Kernkonzept der Musiktherapie. Eine psychologische und empirische Betrachtung [Analogy as the core concept of music therapy. A psychological and empirical essay]. Zeitschrift f ur Musik-, Tanz- und Kunsttherapie, 14(1), 918. Smeijsters, H. (2003b). Forms of feeling and forms of perception. The fundamentals of analogy in music therapy. Nordic Journal of Music Therapy: Theory Building in Music TherapyAn International Archive, 12(1), 7185. Smeijsters, H. (2003c). Handboek creatieve therapie [Handbook of the creative arts therapies]. Bussum: Coutinho. Smeijsters, H. (2005). Sounding the self: Analogy in improvisational music therapy. Gilsum, NH: Barcelona Publishers. Smeijsters, H., & Cleven, G. (2004). Vaktherapie en in de forensische psychiatrie [Arts therapies in forensic psychiatry]. Utrecht: EFP. Stern, D. N. (1985). The interpersonal world of the infant. A view from psychoanalysis and developmental psychology. New York: Basic Books. Stern, D. N. (1995). The motherhood constellation: A unied view of parent-infant therapy. New York: Basic Books. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Grounded theory procedures and techniques. London: Sage Publications. Teasdale, C. (1997). Art therapy as part of a group therapy programme for personality disordered offenders. Therapeutic Communities: The International Journal for Therapeutic and Supportive Organizations, 18(3), 209221. Thaut, M. (1987). A new challenge for music therapy: The correctional setting. Music Therapy Perspectives, 4, 4450. Thaut, M. (1989a). Music therapy, affect modication, and therapeutic change. Music Therapy Perspectives, 7, 5562.

58

H. Smeijsters, G. Cleven / The Arts in Psychotherapy 33 (2006) 3758

Thaut, M. (1989b). The inuence of music therapy interventions on self-rated changes in relaxation, affect, and thought in psychiatric prisoner-patients. Journal of Music Therapy, 26, 155166. Thaut, M. (1992). Music therapy in correctional psychiatry. In W. Davis, K. Gfeller, & M. Thaut (Eds.), An introduction to music therapy: Theory and practice (pp. 273284). Dubuque, IA: W.C. Brown Publishers. Thompson, J. (Ed.). (1998). Prison theatre: Perspectives and practices. London: Jessica Kingsley Publishers. Thompson, J. (1999). Drama workshops for anger management and offending behaviour. London: Jessica Kingsley Publishers. Timmer, S. (2000a). Delict-keten denken binnen dramatherapie. Dramatherapie in een forensisch psychiatrische polikliniek [The use of the concept of the chain of offense in drama therapy. Drama therapy in a forensic psychiatric poly-clinic]. Tijdschrift voor Creatieve Therapie, 19(1), 1218. Timmer, S. (2000b). Inleiding over Kairos. Studiedag Dramatherapeuten in de Forensische Psychiatrie [Introduction about Kairos. Symposium Dramatherapists in Forensic Psychiatry]. Nijmegen. Timmer, S. (2000c). Workshop agressieregulatie. Studiedag Dramatherapeuten in de Forensische Psychiatrie [Workshop aggression regulation. Symposium Dramatherapists in Forensic Psychiatry]. Nijmegen. Timmer, S. (2003). Werkwijzen dramatherapie in de forensische psychiatrie [Treatment modalities of drama therapy in forensic psychiatry]. Nijmegen: Kairos-Pompestichting. Timmer, S. (2004). Zanger gezocht. Dramatherapie binnen een schemagerichte behandeling voor zedendelinquenten [To nd a singer. Drama therapy within a scheme oriented treatment for sexual delinquents]. Tijdschrift voor Creatieve Therapie, 23(1), 1116. Wagner, M. (1997). Aanbod Kreatieve Therapie Muziek in de seksualiteitsgroep polikliniek. Interne publicatie [Creative music therapy in the group of sexual delinquents in the poly-clinic. Internal publication]. Eindhoven: GGzE. Watson, D. M. (2002). Drumming and improvisation with adult male sex offenders. Music Therapy Perspectives, 20(2), 105111. Winnicott, D. W. (1971). Playing and reality. London: Tavistock Publications. Woods, P., Reed, V., & Collins, M. (2001). Measuring communication and social skills in a high security forensic setting using the Behavioural Status Index (BSI). London: Florence Nightingale School of Nursing and Midwifery, Kings College. Wyatt, J. G. (2002). From the eld: Clinical resources for music therapy with juvenile offenders. Music Therapy Perspectives, 20(2), 8088.